Clinton’s Health Plan : Health Plan: A User’s Guide : HEALTH CARE DICTIONARY
The debate over health care reform can be as indecipherable as a doctor’s handwriting. Here is a glossary of the terms and labels that come up again and again:
CAPITATED PAYMENT
A fixed annual fee paid by an insurer to a doctor, hospital or network to care for a patient.
CO-INSURANCE OR CO-PAYMENT
The amount a health insurance policy requires the customer to pay for medical and hospital service, after payment of a deductible. This might be a percentage, such as 20% of a bill, or a certain amount, such as $10 for each office visit.
COST SHIFTING
Low reimbursement rates from government health care programs, such as Medicare and Medicaid often cause doctors and hospitals to increase the prices they charge for treating patients covered by private insurance carriers.
EXPERIENCE RATING
A method of calculating health insurance premiums for a group based on the risks the group presents through its actual illness and hospitalization rates. An employer whose workers are comparatively unhealthy will pay higher rates than a company where no one was sick last year.
FEE FOR SERVICE
The traditional payment system in which patients or insurers are billed by physicians and hospitals for each service rendered.
GATEKEEPER
In a managed care network, this term is given to your regular physician, who controls patient access to specialists.
GLOBAL BUDGETS
Spending ceilings for all health expenditures, public and private, set by the government.
HEALTH MAINTENANCE ORGANIZATIONS (HMO)
A network of doctors and hospitals that provides all care at a set price. Patients are limited to seeing doctors or hospitals within the network. It combines the health care provider and insurance functions by offering pre-paid care.
LONG-TERM CARE
A continuum of maintenance, custodial, and health services to the chronically ill, disabled, or retarded.
MEDICAID
A state-federal program for low-income people who cannot afford medical care on their own. Called Medi-Cal in California. The programs will be folded into the new plan, if passed.
MEDICARE
Federal health insurance program for those 65 and over and the disabled. Unlike Medicaid, eligibility is not based on a person’s income. At this time, Medicare would not be part of the new national health system.
OPEN ENROLLMENT PERIOD
Time during which uninsured employees may join a health care plan or insured employees can switch plans.
POINT OF SERVICE
A term that applies to certain health maintenance organizations and preferred provider organizations. Members in a point of service HMO or PPO can go outside the network of doctors for their care, but they will have to personally pay a bigger share of the bill.
PRE-EXISTING CONDITION
A physical or mental condition someone has before being insured. Policies may exclude coverage for such conditions for a specified period of time. This practice would not be allowed under the Clinton plan.
PREFERRED PROVIDER ORGANIZATIONS (PPO)
A network of doctors and hospitals that agree to discounted fees and certain rules and standards of treatment in exchange for assurances they’ll receive a certain number of patients. Members can go outside the network for care, but they receive lower reimbursement.
RISK POOLS
Arrangements by states to provide health insurance to the unhealthy uninsured who have been rejected for coverage by insurance carriers.
SINGLE-PAYER
A system in which the government pays all covered medical bills. Canada has a single-payer system.
TAX CAP
A limit on tax writeoffs for health insurance that could apply to businesses or employees or both
UNIVERSAL COVERAGE
Providing insurance for all citizens, regardless of health, employment or income.
Sources: Times staff and wire reports, Columbia Journalism Review
TWO KEY TERMS
Managed Competition
A system in which insurance companies and health maintenance organizations (HMOs) bid for business, and consumers pick from among competing health plans. Managed competition’s premise is that the current market for health care is not competitive enough.
Proponents say: Market pressure will produce greater savings and efficiency.
Critics say: With a government-imposed limit on total spending, competitive pressures could lead providers to deny necessary services.
Managed Care
If you belong to a health maintenance organization or a preferred provider network, you’re already under a form of managed care. Managed care holds down costs by requiring pre-admission approval for hospital stays and by closely monitoring other medical services. Managed care plans rely on a network or group of doctors whose reimbursements are limited by advance agreement.
Basics of Clinton Plan
Here is a broad outline of how the President’s plan would work:
1. You pay here: All workers and employers would be required to contribute toward insurance premiums, with workers paying about 20% of the cost of an average plan and employers and about 80%. Additional revenue would come from likely increase in federal tax on cigarettes and possible increase in alcohol tax. Government would pick up tab for the unemployed and others.
2. Money goes to alliance: A government-established agency becomes to go-between for patients and doctors. It negotiates with networks of doctors and hospitals for the best prices for services.
3. You pick a plan: The alliances offer several plans ranging from HMOs to fee-for-service. You pick the plan that suits your needs. If you wanted to retain your doctor, you’d pick a plan he or she subscribes to.
You should know...
A “plan” would list the doctors, hospitals and clinics available to each member.
Those 65 and over would still he covered by Medicare.
Once a year, every consumer would have the chance to charge plans.
Companies with more than 5,000 employees could offer coverage independent of the alliance.
